PLL Form (04-24).pdf
PDF 174 KB Posted
- Attached to
- 4 -Ton Asphalt Hot Box and Recycler
- Solicitation number
- 2135987
- Issued by
- Herkimer County, New York
About this file
This is a Procurement Lobbying Act Certification Form (PLL Form 04-24) issued by the New York State Department of Transportation in conjunction with a Request for Quote (RQ26-001) for the purchase of 4-ton asphalt hot box and recycler units. The form serves as an offerer disclosure and compliance certification document that must be completed by vendors interested in submitting quotations for this equipment purchase. All communications and bid submissions must be directed exclusively to the designated contact persons: Primary Contact Jennifer Walter at (518) 457-9434 or Jennifer.Walter@dot.ny.gov, or Secondary Contact Relina Sosa at (518) 458-5192 or Relina.Sosa@dot.ny.gov. Communication with other individuals or departments may constitute an impermissible contact under state procurement lobbying law and could result in vendor disqualification.
The New York State Department of Transportation intends to advance this purchase using its discretionary purchasing authority under State Finance Law section 163(6), which permits non-competitive procurement from New York State small businesses, businesses certified pursuant to Article 15-A of the New York State Executive Law, service-disabled veteran-owned business enterprises (SDVOB), and vendors selling recycled or remanufactured commodities or technology. The certification form requires offerers to disclose any prior non-responsibility determinations made by government entities within the previous four years, including determinations based on violations of State Finance Law 139-j or intentional provision of false or incomplete information. Offerers must also certify their understanding of and agreement to comply with the designated contact procedures and permissible contact requirements established under State Finance Law 139-j(3) and 139-j(6)(b).
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Other files
| File | Type | Posted |
|---|---|---|
| SS-4-Ton-Hot-Box-Trailer.pdf | ||
| RQ26-001 Cost Proposal Worksheet.xlsx | XLSX spreadsheet | |
| Stock Exhibit (6-2023).pdf | ||
| EO16_certification.pdf | ||
| MANUFACTURER CERTIFICATION Form.pdf | ||
| REQUEST FOR QUOTATION RQ26-001 - Final.pdf | ||
| Executive Order 177_Certification Form.pdf |
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Text version
NEW YORK STATE DEPARTMENT OF TRANSPORTATION
PROCUREMENT LOBBYING ACT CERTIFICATION FORM
Offerer Disclosure of Prior Non-Responsibility Determina�ons and Understanding and Agreement to Comply
PART 1 - NAME AND ADDRESS OF INDIVIDUAL OR ENTITY SEEKING TO ENTER INTO THE PROCUREMENT CONTRACT
ENTITY NAME: ________________________________________
ADDRESS: ________________________________________
Part 2 – DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS
2. Has any government En�ty made a finding of non-responsibility regarding the individual or en�ty seeking to enter into the Procurement Contract in the previous four years?
If YES, please also answer ques�ons 2-4. If NO, skip to ques�on 6. Yes No
3. Was the basis for the finding of non-responsibility due to a viola�on of State Finance Law §139-j? Yes No
4. Was the basis for the finding of non-responsibility due to the inten�onal provision of false or incomplete informa�on to a Government En�ty? Yes No
5. If you answered YES to any of the above ques�ons, please provide details regarding the funding of non-responsibility below:
Government En�ty:
Date of Finding of Non-Responsibility:
Basis of Finding of Non-Responsibility:
(attach additional pages as necessary to provide sufficient detail)
6. Has any Governmental En�ty or other Governmental agency terminated or withheld a
Procurement Contract with the individual or en�ty seeking to enter into the Procurement Contract due to the inten�onal provision of false or incomplete informa�on? Yes No
7. If you answered YES to any of the above ques�ons, please provide details regarding the funding of non-responsibility below:
Government En�ty:
Date of Termina�on or Withholding of Contract::
Basis of Termina�on or Withholding:
(attach additional pages as necessary to provide sufficient detail)
Part 3 – AFFIRMATION of UNDERSTANDING and AGREEMENT TO COMPLY Offerer affirms this _____ day of _________________, 20__ that it understands and agrees to comply with the procedures of the Government En�ty rela�ve to permissible contacts as required by State Finance Law §139-j(3) and §139-j(6)9b).
Business En�ty Name and Address:
By (signature) ______________________________________________ Date: ___________________ Print Name and Title: _________________________________________________________________
Contract/Procurement #
| ContractProcurement: |
| Yes: Off |
| No: Off |
| Yes_2: Off |
| No_2: Off |
| Yes_3: Off |
| No_3: Off |
| Yes_4: Off |
| No_4: Off |
| day of: |
| Print Name and Title: |
| Date: |
| Text1: |
| Text2: |
| Text3: |
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